Get Form C-112 - Ohio Bureau Of Workers' Compensation

Filling out the Form C-112 is essential for employers and employees who wish to select a state other than Ohio for workers' compensation coverage. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the Form C-112 online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the employee's details. Include their first name, middle initial, and last name in the designated fields. Ensure that this information is printed clearly.
3. Next, fill out the employee's address, including the city, state, and ZIP code. Double-check for accuracy to prevent any delays in processing.
4. Indicate the date of completion in the specified field. This helps establish the timeline for the agreement.
5. The employee should sign the form in the designated signature line, affirming their agreement to the terms laid out in the document.
6. Provide the employee's phone number, fax number, and email address. This information ensures that communication regarding the agreement can proceed without issues.
7. Moving on to the employer section, enter the name of the employer or business as it appears on official documents.
8. Next, input the employer's BWC policy number, ensuring it corresponds with records held by the Bureau of Workers' Compensation.
9. Include the employer's address, city, state, and ZIP code, verifying all details for correctness.
10. An authorized person, such as an owner, partner, or officer, must sign the agreement in the employer signature line to validate it.
11. Fill in the title of the person signing the form, along with the date of signing.
12. Provide the Ohio business location address, phone number, fax number, and email address for the employer, as necessary.
13. Review the completed form thoroughly and make any necessary corrections. Once finalized, save the changes, download, or print the form for your records.
14. To submit the completed form, send it to BWC's policy processing via fax or mail as outlined in the instructions.

Take action today and complete your documents online to ensure compliance and secure the proper workers’ compensation coverage.